Checking the Sharks: A Window of Opportunity for Indian Health Care

13 March 2013One Comment

Arradhya Mehta

-An Interview by Mary Liepold, Editor in Chief

Mary interviewed Araddhya Mehtta, who graduated from St Antony’s College, University of Oxford, and has worked for Oxfam UK since 2010 as a Global Health Campaigner. Before that she was the manager of Oxford Hub and worked with the Action North East Trust, Assam; the Centre for Policy Research, Delhi; and the Institute of Development Studies at Sussex University. She did her undergraduate and post graduate degrees in History from St Stephen’s College, Delhi University, and Jawaharlal Nehru University respectively. In her spare time she volunteers for Friends of Seva Mandir UK.

Arradhya, I read the Oxfam report on for-profit medical care in India and I was appalled―especially because the US system, which has been about 50-50, is tipping in the direction of privatization. What experience did you bring to this work?

I grew up in Rajasthan, India. I have worked on health and education issues in the capacity of a policy researcher and public campaigner, primarily in India, where I grew up. More recently, as a global health campaigner in Oxfam Great Britain, I have had the opportunity to work on public health and education in Nepal, Zambia, South Africa, Tanzania, South Africa, and Ghana.

Is health care a human right?

Yes, it’s definitely a central human right, and most nation states have recognized that. In Europe maternal mortality rates have been low because of that thinking―until now, with austerity, it is being reconsidered.

The report says that in 1949 most health care in India was public. What happened?

In 1949 India was a newly independent state and there was energy around the commitment to public health. Full committee reports laid the foundation for a strong public health system. Only 8% of care was by private providers at that time. Now the public sector has had years of under-investment. My analysis is that the government has fallen short in both the hard areas–investment, infrastructure, stemming the brain drain―and in the soft areas, like motivating qualified health workers to go to the rural areas.

The reason why these outrages happen, like the huge numbers of unnecessary hysterectomies that leave poor women saddled with debt, is that the private sector has grown without regulation. Privatization was seen as a solution but it has become a problem. We have global health tourism catering to the wealthy of India and the world, but many of our own citizens have no recourse. User fees have been a huge barrier, also insurance premiums. Both are blockages to care. As high as 80% of families’ out of pocket expenses go to health care, and many people are being pushed into poverty. In some districts and villages there are no public clinics or hospitals, and in those that exist absenteeism may be 64%, when doctors, nurses, and other health workers just don’t show up.

Profit-Based Care is gender-based violence, advocates say

Incentives are not adequate. Regulation is lacking. The government has made an effort, in some cases huge strides, and it’s important to recognize that. But there are shortcomings. So instead of saying government has failed and turning to private health care, we should build a healthy public system. Private care has had a chance and failed. The lesson is that we must beef up the hard and soft elements of a public system so we can have accountability within communities. There must be regulation in place and enforced for the existing private facilities.

Right now there are three tiers. The top tier serves the elite, and even people from the US and Europe and the Middle East, with medical tourism. There are other providers who serve the middle class. Then there’s a range of illegal, unauthorized quacks with no authorization and no control, operating like small businesses, mostly on the basis of profit. The stories in our new report and the ones that have been in the press lately are a big warning sign of the dangers of commercialization. We have seen legal, licensed facilities performing unnecessary and invasive surgeries, poorly done in most cases. What are the incentives for good practice, up against the profit motive?

So what have you seen happen when profit enters the picture?

First of all, when we visit doctors our instinct is to trust them. That’s true for you and me and especially for illiterate and underprivileged women. That trust is exploited. They go in unaware of the crippling debt and the bodily harm that can result.

I visited a village in Rajasthan where 70% of the women have had hysterectomies. Medically, hysterectomies should be a last resort. Over the past three or four years a number of NGOs have investigated these cases and they all agree most are not necessary. Women travel to clinics to be helped and find there is no government hospital, or if there is, it has no doctor, or only a male doctor. They go to these private facilities and wind up with debts and procedures that harm them. Often they’re paying afterwards for 15 to 20 years, selling their land, their livestock, or the jewelry that is often a woman’s only capitol, deciding whether to send a child to school or pay for medical care.

A health worker in one of India's health sub-centers. Photo Credit: Oxfam

That’s painful to think about. What would you like to see happen?

A larger investment in the public health system―financial investment but also in the wider landscape: human resources, equipment, positive incentives, especially incentives for doctors and nurses to serve in rural areas.

And second, regulation of the private sector: for example, insuring the rich hospitals do in fact provide 25% of their care to scheduled tribes and scheduled classes as the law says they should.

The sharks need to be checked, stopped, and all the providers need to be sure they are answering needs and not just maximizing profits. If the public system were improved people would have choices.

Universal health coverage is a topic of debate. A national commission was started in 2006 and it’s working, but it hasn’t done what it should. Last year recommendations were submitted and a planning commission is debating, but it still sees a prominent role for private providers. Right now is a critical moment when we can still salvage the system. There is a window of opportunity.

What will that take? Is anyone organizing public support?

We have many partners working on this. Our report lists them. Prayas is one partner, on a fact-finding mission. Another local NGO, Akhil Bhartiya Grahak Panchayat, is doing legal activism to ensure that these cases are investigated Just last week there was a public interest litigation before the Supreme Court.

More widely, on the issue of public health, the Public Health Foundation and the Peoples Health Movement are key allies to ensure that the government works towards building a robust health system that would prevent the occurrence of such cases in the future. There is the intent to build a grassroots movement.

Public support in building and rebuilding the government health system would be key in addressing these issues. It is important that the Indian government and its citizens prioritize healthcare provision. If universal health coverage, free at the point of use, is provided to all citizens we can mend the gaps in the system that currently lead people to seek irresponsible and expensive care.

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